Nursing Elites

1. What are the signs and symptoms of hyperkalemia and how should it be managed?

• A. Muscle weakness and cardiac arrhythmias; administer calcium gluconate
• B. Confusion and bradycardia; administer insulin and glucose
• C. Fatigue and irregular heart rate; administer diuretics
• D. Nausea and vomiting; administer sodium bicarbonate

Correct answer: A

Rationale: The signs and symptoms of hyperkalemia include muscle weakness and cardiac arrhythmias, making choice A correct. Hyperkalemia can lead to dangerous cardiac effects, and calcium gluconate is used to stabilize the heart by antagonizing the effects of potassium. Choices B, C, and D describe symptoms and interventions that are not typically associated with hyperkalemia. Confusion and bradycardia are not common in hyperkalemia, and insulin and glucose are used in hyperkalemia only under specific circumstances. Fatigue and irregular heart rate are vague symptoms, and diuretics are not the primary treatment for hyperkalemia. Nausea and vomiting are nonspecific symptoms and sodium bicarbonate is not indicated for the management of hyperkalemia.

2. A nurse is caring for a client who is experiencing a situational crisis following the loss of a job. The client states, 'I don't think I can go through this again.' Which of the following actions is the nurse's priority?

• A. Refer the client to a mental health counselor
• B. Encourage the client to express their feelings
• C. Determine if the client is experiencing psychotic thinking
• D. Ask the client about their social support system

Correct answer: C

Rationale: In this situation, the nurse's priority is to determine if the client is experiencing psychotic thinking as it addresses the immediate safety concern. Psychotic thinking may pose a risk to the client's safety or the safety of others. Referring the client to a mental health counselor (choice A) may be appropriate but not the priority when safety is a concern. Encouraging the client to express their feelings (choice B) and asking about their social support system (choice D) are essential aspects of care but are secondary to addressing immediate safety issues.

3. A nurse is caring for a client who is 2 hours postoperative following an appendectomy. Which of the following findings should the nurse report to the provider?

• A. Urine output of 20 mL/hr.
• B. Temperature of 36.5°C (97.7°F).
• C. Sanguineous drainage on the surgical dressing.
• D. WBC count of 9,000/mm3.

Correct answer: A

Rationale: The correct answer is A: Urine output of 20 mL/hr. A urine output less than 30 mL/hr can indicate decreased renal perfusion, potentially due to hypovolemia or other issues, and should be reported to the provider. B: A temperature of 36.5°C (97.7°F) falls within the normal range and does not require immediate reporting. C: Sanguineous drainage on the surgical dressing is expected in the early postoperative period and should be monitored but does not need immediate reporting unless excessive. D: A WBC count of 9,000/mm3 is within the normal range and does not indicate an immediate concern.

4. A nurse is caring for a client post-abdominal surgery who has an NG tube. The client reports nausea and a decrease in gastric output. What should the nurse do first?

• A. Turn the client onto their left side
• B. Irrigate the NG tube with sterile water
• C. Increase the suction pressure to relieve the blockage
• D. Remove the NG tube and replace it with a new one

Correct answer: B

Rationale: The correct answer is to irrigate the NG tube with sterile water first. This action helps to relieve blockages that may be causing the decrease in gastric output and nausea. Turning the client onto their left side may not directly address the issue with the NG tube. Increasing the suction pressure can further exacerbate the problem and should not be done without assessing the situation first. Removing the NG tube and replacing it with a new one is a more invasive step that should be considered only if other measures are unsuccessful.

5. A nurse is caring for a client who has dementia and frequently gets out of bed unsupervised. What is the best intervention to prevent falls?

• A. Place a bed exit alarm
• B. Use restraints to prevent the client from getting out of bed
• C. Ask the client's family to stay at the bedside
• D. Encourage frequent ambulation with assistance

Correct answer: A

Rationale: The best intervention to prevent falls in a client with dementia who gets out of bed unsupervised is to place a bed exit alarm. This device alerts staff when the client attempts to leave the bed, allowing timely intervention to reduce the risk of falls. Using restraints (choice B) can lead to physical and psychological harm and should be avoided unless absolutely necessary. Asking the client's family to stay at the bedside (choice C) may not be feasible at all times and does not provide a continuous monitoring solution. Encouraging frequent ambulation with assistance (choice D) is beneficial for mobility but may not address the immediate risk of falls associated with unsupervised bed exits.

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